Transcript LRTforNECLESWorkshopOct2011

Responsible Respiratory
Prescribing
Dr Louise Restrick* and Dr Chris Cooper London Respiratory Team
NHS Islington and Whittington Health*
NHS London Respiratory Team
Aim is to improve the experience of Londoners
with COPD and reduce the impact of the disease
Funded by DH 2010-13
Clinically-led multi-disciplinary team (0.5 -1 day/week)
Community and hospital health professionals
Patient/carer voice
Value Framework
Health
Outcomes
Value
=
Patient defined
Health Outcomes
bundle of care
Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
Cost
Right Care Respiratory Priorities
Quit smoking support and therapy as
treatment for COPD (and asthma)
Responsible Respiratory
Prescribing …
… of Medicines and Oxygen
Pulmonary Rehabilitation
COPD ‘Value’ Pyramid
What we know…. Cost/QALY
Triple Therapy
£35,000£187,000/QALY
LABA
£8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £?1,000/QALY in “at risk” population
NICE Respiratory Prescribing
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‘Ensure all patients with COPD are on the
appropriate therapy for the severity of,
and symptoms from, their disease.’
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‘Offer nicotine replacement therapy,
varenicline or bupropion (unless
contraindicated) combined with a support
programme to optimise quit rates… to all
people with COPD who still smoke at
every opportunity.’
Cost of Respiratory Medication
by BNF Chapters
2287
2400
Others
1783
1873
Central nervous system
1615
1513
Cardiovascular system
956
1053
Endocrine system
983
1026
Respiratory system
~£1 billion on respiratory
medication not including
antibiotics…
463
506
Nutrition & blood
440
463
Gastro-intestinal system
2009
2010
0
Source: NHS Information Centre
500
1000
1500
Net ingredient cost (£ millions)
2000
2500
Volume of Respiratory Medication
210
217
Others
155
164
Central nervous system
277
286
Cardiovascular system
58
60
Respiratory system
77
83
Endocrine system
41
45
Nutrition & blood
Gastro-intestinal system
2009
2010
but a relatively low
volume of respiratory
prescriptions ...
69
74
0
50
Source: NHS Information Centre
100
150
200
Prescription items (millions)
250
300
Item cost of Respiratory Medication
Respiratory items are the most expensive category of
item prescribed .....
…inhalers
10.91
11.07
Others
11.53
11.46
Central nervous system
5.87
5.3
Cardiovascular system
17.02
17.16
Respiratory system
12.38
12.73
Endocrine system
11.35
11.36
Nutrition & blood
Gastro-intestinal system
2009
2010
0.00
6.41
6.29
2.00
Source: NHS Information Centre
4.00
6.00
8.00
10.00
12.00
14.00
Average net ingredient cost per item (£)
16.00
18.00
NHS budget & respiratory medication
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Seretide (all) is the most expensive drug in NHS
Seretide 250 Evohaler is the most expensive
individual item (second is atorvastatin)
Tiotropium is 6th most expensive
Symbicort 200 is 5th most expensive item
Of the top 5 costliest drugs to the NHS currently 3 are
inhalers
Source: NHS Information Centre
Spiriva Handihaler
Seretide 500 Accuhaler
Symbicort 400/12
Flixotide 500 Accuhaler
Seretide 250 Accuhaler
Seretide 100 Accuhaler
Seretide 250 Evohaler
Serevent Accuhaler
Flixotide 250 Accuhaler
Symbicort 200/6
Flixotide 250 Evohaler
Seretide 125 Evohaler
Symbicort 100/6
Fostair
Serevent evohaler
Flixotide 125 Evohaler
Seretide 50 Evohaler
Flixotide 100 Accuhaler
Pulmicort Turbohaler 200
Qvar 100
Clenil 200
Clenil 100
Flixotide 50 evohaler
Ipratropium MDI
Salbutamol 100 MDI
Price per puff of inhaled therapy
Price Per Puff of Inhaler, June 2011
£1.20
£1.00
£0.80
£0.60
£0.40
£0.20
£0.00
COPD ‘Value’ Pyramid
What we know…. Cost/QALY
Triple
Therapy
£35,000£187,000
LABA
£8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £?1,000/QALY in “at risk” population
London Combination Inhaler Prescribing
1600.00
Seretide
1400.00
1200.00
1000.00
800.00
600.00
400.00
200.00
0.00
Symbicort
Doing the Right things Right
Inhaler technique
• >90% of patients cannot use an MDI effectively
• 91% of healthcare professionals who teach use of
an MDI cannot demonstrate it correctly*
• Even with effective technique, maximum lung
deposition from MDI is 15%
• Large volume spacer increases deposition to 30%
*Thorax 2010;65:A117
Responsible Respiratory Prescribing
Best value from inhaled therapy
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Smokers offered support to stop smoking and
prescribed NRT therapy each time inhalers
prescribed…..
Use NICE criteria
No new inhaler without patient-centred
education, training and review
Mechanisms for reducing duplicate
prescribing
Steroid cards for high dose ICS/combinations
Responsible Respiratory Prescribing
Best value from Prednisolone
No evidence that EC prednisolone tablets (red)
result in fewer GI problems or protect against peptic
ulceration
EC prednisolone costs 6-15 times more than plain
prednisolone (white)
Switch from EC prednisolone to prednisolone could
save £2 million per year in London
Right Care for COPD
• Doing the Right Thing – what is
evidenced based and cost effective?
– Encourage Responsible Prescribing
– Supporting patients to stop smoking as a
priority when seeing patients with respiratory
symptoms
– Ensure that all eligible patients are referred for
pulmonary rehabilitation
Source: NHS Information Centre
Mechanisms to support Responsible
Respiratory Prescribing
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QOF Medicines management M6,10,11-12
QOF Quality & productivity:QP1-5
Medicines Audits
COPD Guidelines
COPD Local Enhanced Service (LES)
Systems solutions
Prescribing Incentives/Commissioning for
Quality Schemes
Doing the Right things Right
Minimise Waste – Maximise safety
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Each patient with COPD or asthma is using an inhaler
device that works for them (MDI with spacer or DPI)
Each patient with COPD or asthma has learnt the right
technique for drug delivery into the lung
Each patient with COPD or asthma uses their inhaled
therapy regime as prescribed for evidence-based benefit
Each patient with COPD or asthma has safe inhaled
therapy ie minimum evidenced based dose of inhaled
steroid for their stage of disease
Increasing value from prescribing systems
60%
EC prednisolone as % of all prednisolone prescribed
NHS Haringey
Percentage
Practices informed by letter that
reducing EC prednisolone would be
part of an additional savings initative.
55%
50%
45%
40%
‘Scriptswitch’
message & Practice
support ; pharmacists
going into practices
and making changes.
35%
30%
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Right Care, Value and QIPP in COPD
• Doing the right things
 Helping people to stop smoking
 Helping people complete pulmonary
rehabilitation
 Helping people get the right medicines
• And doing the right things right
 Intensive stop smoking counselling + drugs
 The right PR programme in the right place
 The right inhaler and the correct technique
LRT: 7 Key Prescribing Messages
1.
Respiratory medications are expensive
Doing the Right Things:
2.
When prescribing any new respiratory inhaler, ensure that the patient has undergone NICErecommended support to stop smoking
3. Pulmonary rehabilitation is a cost effective alternative to stepping up to triple therapy and
should be the preferred option if available and the patient is suitable
4.
5.
6.
7.
Doing the Right Things Right:
When prescribing any inhaled medication, ensure that the patient has undergone patient
centred education about the disease and inhaler technique training by a competent trainer
When prescribing an MDI (except salbutamol), ensure that a spacer is also prescribed and
will be used
When prescribing high dose inhaled corticosteroids, ensure that the patient is issued with an
inhaled steroid safety card
No Prednisolone EC prescribing without good clinical reason